Oncologic emergencies and urgencies: A comprehensive review.

Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.

Progressive liver, kidney, and heart degeneration in children and adults affected by TULP3 mutations.

Organ fibrosis is a shared endpoint of many diseases, yet underlying mechanisms are not well understood. Several pathways governed by the primary cilium, a sensory antenna present on most vertebrate cells, have been linked with fibrosis. Ciliopathies usually start early in life and represent a considerable disease burden. We performed massively parallel sequencing by using cohorts of genetically unsolved individuals with unexplained liver and kidney failure and correlated this with clinical, imaging, and histopathological analyses. Mechanistic studies were conducted with a vertebrate model and primary cells. We detected bi-allelic deleterious variants in TULP3, encoding a critical adaptor protein for ciliary trafficking, in a total of 15 mostly adult individuals, originating from eight unrelated families, with progressive degenerative liver fibrosis, fibrocystic kidney disease, and hypertrophic cardiomyopathy with atypical fibrotic patterns on histopathology. We recapitulated the human phenotype in adult zebrafish and confirmed disruption of critical ciliary cargo composition in several primary cell lines derived from affected individuals. Further, we show interaction between TULP3 and the nuclear deacetylase SIRT1, with roles in DNA damage repair and fibrosis, and report increased DNA damage ex vivo. Transcriptomic studies demonstrated upregulation of profibrotic pathways with gene clusters for hypertrophic cardiomyopathy and WNT and TGF-ß signaling. These findings identify variants in TULP3 as a monogenic cause for progressive degenerative disease of major organs in which affected individuals benefit from early detection and improved clinical management. Elucidation of mechanisms crucial for DNA damage repair and tissue maintenance will guide novel therapeutic avenues for this and similar genetic and non-genomic diseases.

Early diagnosis and management of cardiac amyloidosis: A clinical perspective.

Cardiac amyloidosis multidisciplinary team (MDT). We propose the creation of a multidisciplinary team (MDT) for cardiac amyloidosis in which internal medicine physicians could take a lead role in coordinating other specialists involved in patient care. Created with BioRender.com.

An Opportunity for Change: Principles for Reforming Internal Medicine Inpatient Conferences.

Inpatient educational conferences are a key part of internal medicine residency training. Many residencies made conferences virtual during the COVID-19 pandemic, and are now returning to in-person sessions. As we navigate this change, we can seize this opportunity to re-evaluate the role that inpatient conferences serve in resident education. In this paper, we briefly review the history of inpatient educational conferences before offering five recommendations for improvement. Our recommendations include grounding conference formats in educational theory, leveraging the expertise of all potential educators, broadening content to include health equity and justice throughout all curricula, and explicitly focusing on cultivating community among participants. Recognizing that each residency program is different, we anticipate that these recommendations may be implemented differently based on program size, available resources, and current institutional practices. We also include examples of prior successful curricular reforms aligned with our principles. We hope these recommendations ensure inpatient conferences continue to be a central part of residency education for future generations of internal medicine residents.

Stereotype Threat and Gender Bias in Internal Medicine Residency: It is Still Hard to be in Charge.

BACKGROUND: Despite similar numbers of women and men in internal medicine (IM) residency, women face unique challenges. Stereotype threat is hypothesized to contribute to underrepresentation of women in academic leadership, and exploring how it manifests in residency may provide insight into forces that perpetuate gender disparities. OBJECTIVE: To quantify the prevalence of stereotype threat in IM residency and explore experiences contributing to that stereotype threat. DESIGN: We used a mixed methods study design. First, we surveyed IM residents using the Stereotype Vulnerability Scale (SVS) to screen for stereotype threat. Second, we conducted focus groups with women who scored high on the SVS to understand experiences that led to stereotype threat. PARTICIPANTS: The survey was sent to all IM residents at University of California, San Francisco (UCSF), in September-November 2019. Focus groups were conducted at UCSF in Spring 2020. APPROACH: The survey included an adapted version of the SVS. For focus groups, we developed a focus group guide informed by literature on stereotype threat. We used a thematic approach to data analysis. The mixed methods design enabled us to draw metainferences by integrating the two data sources. KEY RESULTS: Survey response rate was 61% (110/181). Women were significantly more likely than men to have a score indicating stereotype threat vulnerability (77% vs 0%, p < 0.001). Four themes from focus groups characterized women's experiences of gender bias and stereotype threat: gender norm tension, microaggressions and sexual harassment, authority questioned, and support and allyship. CONCLUSIONS: Gender-based stereotype threat is highly prevalent among women IM residents. This phenomenon poses a threat to confidence and ability to execute patient care responsibilities, detracting from well-being and professional development. These findings indicate that, despite robust representation of women in IM training, further attention is needed to address gendered experiences and contributors to women's vulnerability to stereotype threat.

End of Affirmative Action-Who Is Impacted Most? Analysis of Race and Sex Among US Internal Medicine Faculty.

BACKGROUND: For over 50 years, the United States (US) used affirmative action as one strategy to increase diversity in higher education including medical programs, citing benefits including training future public and private sector leaders. However, the recent US Supreme Court ending affirmative action in college admissions threatens advancements in the diversity of medical college faculty. OBJECTIVE: Our study evaluated the demographic trends in Internal Medicine (IM) faculty in the US by assessing sex and race/ethnicity diversity to investigate who is likely to be impacted most with the end of affirmative action. DESIGN: Longitudinal retrospective analysis SUBJECTS: IM faculty from the Association of American Medical Colleges faculty roster from 1966 to 2021 who self-reported sex and ethnicity MAIN OUTCOMES: The primary study measurement was the annual proportion of women and racial/ethnic groups among IM faculty based on academic rank and department chairs. RESULTS: Although racial/ethnic diversity increased throughout the era of affirmative action, African American, Hispanic, and American Indian populations remain underrepresented. White physicians occupied > 50% of faculty positions across academic ranks and department chairs. Among the non-White professors, Asian faculty had the most significant increase in proportion from 1966 to 2021 (0.6 to 16.6%). The percentage of women increased in the ranks of professor, associate professor, assistant professor, and instructor by 19.5%, 27.8%, 25.6%, and 26.9%, respectively. However, the proportion of women and racial/ethnic minority faculty decreased as academic rank increased. CONCLUSION: Despite an increase in the representation of women and racial/ethnic minority IM faculty, there continues to be a predominance of White and men physicians in higher academic ranks. With the end of affirmative action, this trend has the danger of being perpetuated, resulting in decreasing diversity among IM faculty, potentially impacting patient access and health outcomes.

Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements.

BACKGROUND: Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE: To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN: This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS: Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH: Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS: Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS: Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.

The Organization of Academic General Internal Medicine Practice at the Top Primary Care Schools.

BACKGROUND: While prior studies have explored staffing infrastructure for primary care practices in general, little is known about the range of academic primary care practice models and supports available for academic general internists. OBJECTIVE: To characterize the range of practice arrangements and expectations for attending academic physicians in general internal medicine (GIM) practices at the top 22 medical schools across the USA. DESIGN: Cross-sectional survey administered electronically between October 30, 2022, and December 28, 2022. PARTICIPANTS: Clinical leaders in GIM at the top 22 primary care medical schools, as identified by the 2023 US News and World Report Rankings. MAIN MEASURES: Clinical load, productivity expectations, cross-coverage, and team-based care models. KEY RESULTS: Twenty-two leaders responded, representing 68% (15/22) of medical schools surveyed. The practices were mostly in urban locations (18/22, 82%) and 86% (19/22) included residents. Practices ranged from 7 to 200 PCPs and from 3 to 112 clinical FTEs. A full-time (1.0 FTE) clinical role for academic attending GIM physicians entailed a median of 9 (IQR 8, 10) weekly half-day clinic sessions, with a median panel size expectation of 1600 (IQR 1450, 1850) patients and a median yearly RVU expectation of 5200 (IQR 4161, 5891) yearly RVUs generated. Staff support was most commonly present for prescription refills and patient portal message checks. It was less commonly available for time sensitive form completion. Occasional clinical coverage for other physicians was an expectation at all practices. CONCLUSIONS: In this study, we characterize the organization of and supports available in academic GIM practices affiliated with the top primary care medical schools. Our findings provide comparative information for leaders of academic GIM practices seeking to enhance primary care delivery for their faculty and trainees. They also highlight areas where standardization may be beneficial across academic GIM.

How Internal Medicine Clerkship Directors Are Using Entrustable Professional Activities: A National Survey Study.

BACKGROUND: In the present assessment environment in undergraduate medical education at U.S. medical schools, the prevalence and implementation of Entrustable Professional Activities (EPAs) in internal medicine (IM) clerkships are not well understood. OBJECTIVE: To describe the prevalence and approach to EPA use in U.S. IM clerkships. DESIGN: Cross-sectional, nationally representative survey of core IM clerkship directors. PARTICIPANTS: One-hundred forty IM clerkship directors at Liaison Committee on Medical Education-accredited U.S./U.S. territory-based allopathic medical schools with membership in the Clerkship Directors in Internal Medicine (CDIM) as of December 2022. MAIN MEASURES: Use of EPAs in IM core clerkships, including use for grading, types of EPAs, use of supportive measures for assessment, and current validity frameworks. KEY RESULTS: The survey response was 80% (112/140); two additional respondents completed the section on EPA use (n = 114). Approximately half of respondents (47%) reported their IM clerkship used EPAs. Among schools accredited after 1977, a higher percentage was associated with having incorporated EPAs (p = 0.03). The Association of American Medical Colleges Core EPAs for Entering Residency (CEPAER) was the most common framework used by Clerkship Directors (CDs) for developing EPAs (55%). Most CDs (56%) used EPAs for both formative and summative assessments, and approximately half of CDs (48%) used EPAs for a portion of the final grade determination. CDs who used EPAs were no more likely to report efforts to ensure the validity of assessment, the use of faculty development, or that written assessments were a valid measure of students' performance compared to those who did not use EPAs. CONCLUSIONS: Although EPAs have experienced substantial uptake in the IM clerkship and contribute to formative and summative assessment of learners, their use does not appear to be associated with enhanced efforts to obtain validity information.

Perspectives and Recommendations from Hospitalized Patients with Substance Use Disorders: A Qualitative Study.

BACKGROUND: Individuals with substance use disorders (SUDs) are hospitalized in growing numbers. Stigma is pervasive among their hospital providers, and SUD management during medical admissions is often inadequate. However, little is known about how these patients perceive their care quality. In particular, few studies have explored their positive care perceptions or recommendations for improvement. OBJECTIVE: To explore perspectives on positive aspects, negative aspects, and consequences of care, as well as recommendations for improvement among hospitalized patients with SUDs. DESIGN AND PARTICIPANTS: We conducted semi-structured, in-depth bedside interviews (n = 15) with patients who have been diagnosed with a SUD and were admitted to medical or surgical floors of an urban academic medical center. APPROACH: Interviews explored patients' hospital experiences and recommendations for improvement. The interviews were audio-recorded, transcribed verbatim, and imported into NVivo software. Two reviewers independently coded the transcripts using interpretative phenomenological analysis and inductive thematic analysis according to grounded theory, and recurring themes were identified from the data. Patients' demographic and clinical data were analyzed with descriptive statistics. KEY RESULTS: Perceived clinical and emotional proficiency were the most important components of positive experiences, whereas perceived bias and stigmatized attitudes, clinical improficiency, and inhumane treatment were characteristic of negative experiences. Such care components were most consequential for patients' emotional well-being, trust, and care quality. Recommendations for improving care included specific suggestions for initiating and promoting continued recovery, educating, and partnering in compassionate care. CONCLUSIONS: Hospitalized patients with SUDs often experience lower quality and less compassionate care linked to pervasive stigma and poor outcomes. Our study highlights under-recognized perspectives from this patient population, including socioemotional consequences of care and recommendations grounded in lived experiences. By striving to advance our care in accordance with patients' viewpoints, we can turn hospitalizations into opportunities for engagement and promoting recovery.

A Scoping Review of Obstetrics and Gynecology Curricula in Primary Care Residency Programs.

BACKGROUND: While Women's Health (WH) is a priority for primary care, (Family Medicine (FM), Internal Medicine (IM), Pediatrics (Peds), and combined Medicine/Pediatrics (Med/Peds)), residency curricula remain heterogeneous with deficits in graduates' WH expertise and skills. The overall objective of this study was to assess the quality of WH curricula at primary care residency programs in the United States (US), with a focus on topics in obstetrics and gynecology (OBGYN). METHODS: PubMed®, ERIC, The Cochrane Library, MedEdPORTAL, and professional organization websites were systematically searched in 2019 and updated in 2021. Included studies described OBGYN educational curricula in US primary care residency programs. Following abstract screening and full-text review, data from eligible studies was abstracted and quality assessed using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: A total of 109 studies met the inclusion criteria. Over a quarter of studies were interdepartmental or interdisciplinary. The most common single-department studies were IM (38%) and FM (26%). Twenty (25%) studies addressed comprehensive OBGYN curricula; the most common individual topics were cervical and breast cancer screening (31%) and contraception (16%). Most studies utilized multiple instructional modalities, most commonly didactics (54%), clinical experiences (41%), and/or simulation (21%). Most studies included self-reported outcomes by residents (70%), with few (11%) reporting higher-level assessments (i.e., patient, or clinical outcomes). Most studies were single-group pre- and post-test (42%) with few randomized controlled trials (4%). The mean MERSQI score for studies with sufficient data (90%) was 9.8 (range 3 to 15.5). DISCUSSION: OBGYN educational curricula for primary care trainees in the US was varied with gaps in represented residents, content, assessments, and study quality.

"What's Going to Happen?": Internal Medicine Resident Experiences of Uncertainty in the Care of Older Adults.

PURPOSE: Internal medicine residents care for clinically complex older adults and may experience increased moral distress due to knowledge gaps, time constraints, and institutional barriers. We conducted a phenomenological study to explore residents' experiences and challenges through the lens of uncertainty. METHODS: Between January and March 2022, six focus groups were conducted comprising a total of 13 internal medicine residents in postgraduate years 2 and 3, who had completed a required 2-week geriatrics rotation. Applying the Beresford taxonomy of uncertainty as a conceptual model, data were analyzed using the framework method. RESULTS: All challenging experiences described by residents caring for older adults were linked to uncertainty. Sources of uncertainty were categorized and mapped to the Beresford taxonomy: (1) lack of geriatrics knowledge or clinical guidelines (technical); (2) difficulty applying knowledge to complex older adults (conceptual); and (3) lack of longitudinal relationship with the older patient (personal). Residents identified capacity evaluation and discharge planning as two major geriatric knowledge areas linked with uncertainty. While the majority of residents reacted to uncertainty with some degree of distress, several reported positive coping strategies. CONCLUSIONS: Internal medicine residents face uncertainty when caring for older adults, particularly related to technical and conceptual factors. Strategies for mitigating uncertainty in the care of older adults are needed given links with moral distress and trainee well-being.

Social and clinical predictors of perianal colonisation by multidrug-resistant bacteria for geriatric patients in the internal medicine service.

BACKGROUND: Colonisation by multidrug-resistant (MDR) bacteria is a global health issue. The identification of patients with a higher risk of colonisation is essential. Patients admitted to internal medicine services might represent a vulnerable population with a high risk of colonisation. This study was the first to assess social and clinical variables associated with a higher risk of perianal colonisation by MDR bacteria in a Spanish cohort of patients admitted to internal medicine service. METHODS: Patients admitted to an internal medicine service during 12 months of recruitment (1 March 2022 to 1 March 2023) were included in the study. Perianal swabs were performed at admission to identify the presence of MDR bacteria. Social and clinical variables were collected following a directed acyclic graph. A cluster analysis was performed to identify clinical profiles of higher risk. Bivariate analyses and multivariable logistic regression models were fitted to identify potential predictors of MDR bacteria colonisation. RESULTS: A total of 245 patients, according to the required sample size, were included. Of them, 46 (18.8%) were colonised by MDR bacteria in perianal swabs. Female sex, age > 80 years, dependency on activities of daily living, cognitive deterioration and living in long-term care facilities constituted the highest risk clinical profile. After adjustments, living in long-term care facilities and malnutrition remained the main risk factors identified. CONCLUSION: Patients admitted to internal medicine services presented a high frequency of perianal colonisation by MDR bacteria. Social and clinical variables associated with bio-psycho-social susceptibility were associated with colonisation. Special surveillance is needed in internal medicine services to control the transmission.

Profile, reasons for hospitalization and nursing diagnoses of refugee-native patients admitted to internal medicine clinic-an evaluation from nursing perspective.

PURPOSE: The study aims to evaluate the hospitalization diagnoses and nursing diagnoses of the refugee and local population hospitalized in internal medicine clinics, which are especially important in the early diagnosis, treatment, and rehabilitation of chronic diseases, and to emphasize their importance in nursing care. METHODS: The study was carried out in a descriptive retrospective design. The files of 3563 patients admitted to the internal medicine clinic of a training and research hospital in Türkiye in 2022 were evaluated. SPSS 26.0 program was used for data analysis. RESULTS: In the study, 95.3% of hospitalizations were native and 4.7% were refugee patients. It was determined that refugee patients admitted to the internal medicine service had a lower mean age compared to the native population (p < 0.05), but there was no difference in the duration of hospitalization (p > 0.05). When the medical diagnoses of hospitalization were examined, it was determined that the highest number of hospitalizations in the native and refugee populations were for bacterial infections in both genders. In nursing diagnoses, it was determined that both populations and genders were diagnosed with infection risk by the medical diagnoses of the patients. CONCLUSION: As a result of the study, it was observed that the duration of hospitalization, reasons for hospitalization, and nursing diagnoses of local and refugee patients were similar. In addition, it was determined that the patients' medical hospitalization diagnoses and nursing diagnoses were compatible.

Risk Factors for Falls Among Hospitalized Medical Patients - A Systematic Review and Meta-analysis.

OBJECTIVE: To identify and quantify risk factors for in-hospital falls in medical patients. DATA SOURCES: Six databases (MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, and Google Scholar) were systematically screened until April 11, 2023, to identify relevant articles. STUDY SELECTION: All titles and abstracts of the retrieved articles were independently screened by 2 researchers who also read the full texts of the remaining articles. Quantitative studies that assessed risk factors for falls among adult patients acutely hospitalized were included in the review. Publications that did not capture internal medicine patients or focused on other specific populations were excluded. DATA EXTRACTION: Information on study characteristics and potential risk factors were systematically extracted. Risk of bias was assessed using the Quality in Prognosis Studies tool. Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analyses of Observational Studies in Epidemiology guidelines were followed for reporting. DATA SYNTHESIS: The main outcome was any in-hospital falls. Using a random-effects meta-analysis model, association measures for each risk factor reported in 5 or more studies were pooled. Separate analyses according to effect measure and studies adjusted for sex and age at least were performed. Of 5067 records retrieved, 119 original publications from 25 countries were included. In conclusion, 23 potential risk factors were meta-analyzed. Strong evidence with large effect sizes was found for a history of falls (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.63-3.96; I2, 91%), antidepressants (pooled OR, 2.25; 95% CI, 1.92-2.65; I2, 0%), benzodiazepines (OR, 1.97; 95% CI, 1.68-2.31; I2, 0%), hypnotics-sedatives (OR, 1.90; 95% CI, 1.53-2.36; I2, 46%), and antipsychotics (OR, 1.61; 95% CI, 1.33-1.95; I2, 0%). Furthermore, evidence of associations with male sex (OR, 1.22, 95% CI, 0.99-1.50; I2, 65%) and age (OR, 1.17, 95% CI, 1.02-1.35; I2, 72%) were found, but effect sizes were small. CONCLUSIONS: The comprehensive list of risk factors, which specifies the strength of evidence and effect sizes, could assist in the prioritization of preventive measures and interventions.

Ethical argument for establishing good manufacturing practice for phage therapy in the UK.

Antimicrobial resistance (AMR) poses an increasing threat to patient care and population health and there is a growing need for novel therapies to tackle AMR. Bacteriophage (phage) therapy is a re-emerging antimicrobial strategy with the potential to transform how bacterial infections are treated in patients and populations. Currently, in the UK, phages can be used as unlicensed medicinal products on a 'named-patient' basis. We make an ethical case for why it is crucially important for the UK to invest in Good Manufacturing Practice (GMP) for both ongoing unlicensed and future licensed phage therapy. Access to phages produced to GMP (GMP phages) will ensure effective patient care and better outcomes as well as health systems benefits. The UK also has the potential to become a global leader in the timely and cost-efficient manufacturing and supply of a therapy that meets internationally recognised standards.

Global meta-analysis of physicians' experiences of workplace sexual harassment by patients.

The World Health Organization recognises that sexual harassment is an occupational hazard in medicine, but the prevalence of sexual harassment by patients is unknown. This global meta-analysis found that a pooled prevalence of 45.13% of 18 803 physicians from several specialities (e.g. internal medicine and surgery) have ever experienced it. Hospitals should implement protective measures such as panic alarms for night shifts and isolated wards.

Impact of a general medicine consultant-led ward round in the emergency department.

BACKGROUND: Patients requiring admission to the general medicine wards in a public hospital are usually assessed by a medical registrar. This study is based at a metropolitan public hospital in Melbourne where the majority of general medicine patients in the emergency department (ED) are not seen by a consultant physician until they are transferred to the ward. AIMS: To assess the impact of general medicine consultant-led ward rounds (CWRs) in the ED on patient length of stay (LOS). METHODS: One-month audit was conducted of all patients admitted to general medicine and awaiting transfer to ward from ED at a metropolitan public hospital in Melbourne. A general medicine CWR was then implemented in the ED, followed by another 1-month audit, with the primary outcome being LOS and the secondary outcome being 30-day readmission rate. Additionally, admitting medical registrars were invited to complete a survey before and after the implementation of CWRs to assess satisfaction rate. RESULTS: Data from electronic medical records were analysed for 162 patients (90 preimplementation group and 72 postimplementation group). The median LOS was 6 days in the preimplementation group and 4 days in the postimplementation group (P = 0.014). There was no significant difference in 30-day readmission rates. Surveys showed admitting medical registrars reported a reduced level of stress and fewer barriers to seeking consultant input following implementation. CONCLUSIONS: A CWR in the ED has led to decreased LOS for general medicine patients and improved satisfaction among junior medical staff.

The association between primary care appointment lengths and opioid prescribing for common pain conditions.

BACKGROUND: While brief duration primary care appointments may improve access, they also limit the time clinicians spend evaluating painful conditions. This study aimed to evaluate whether 15-minute primary care appointments resulted in higher rates of opioid prescribing when compared to ≥ 30-minute appointments. METHODS: We performed a retrospective cohort study using electronic health record (EHR), pharmacy, and administrative scheduling data from five primary care practices in Minnesota. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 scheduled for 15-minute appointments were propensity score matched to those scheduled for ≥ 30-minutes. Sub-groups were analyzed to include patients with acute and chronic pain conditions and prior opioid exposure. Multivariate logistic regression was performed to examine the effects of appointment length on the likelihood of an opioid being prescribed, adjusting for covariates including ethnicity, race, sex, marital status, and prior ED visits and hospitalizations for all conditions. RESULTS: We identified 45,471 eligible acute primary care visits during the study period with 2.7% (N = 1233) of the visits scheduled for 15 min and 98.2% (N = 44,238) scheduled for 30 min or longer. Rates of opioid prescribing were significantly lower for opioid naive patients with acute pain scheduled in 15-minute appointments when compared to appointments of 30 min of longer (OR 0.55, 95% CI 0.35-0.84). There were no significant differences in opioid prescribing among other sub-groups. CONCLUSIONS: For selected indications and for selected patients, shorter duration appointments may not result in greater rates of opioid prescribing for common painful conditions.

ChatGPT With GPT-4 Outperforms Emergency Department Physicians in Diagnostic Accuracy: Retrospective Analysis.

BACKGROUND: OpenAI's ChatGPT is a pioneering artificial intelligence (AI) in the field of natural language processing, and it holds significant potential in medicine for providing treatment advice. Additionally, recent studies have demonstrated promising results using ChatGPT for emergency medicine triage. However, its diagnostic accuracy in the emergency department (ED) has not yet been evaluated. OBJECTIVE: This study compares the diagnostic accuracy of ChatGPT with GPT-3.5 and GPT-4 and primary treating resident physicians in an ED setting. METHODS: Among 100 adults admitted to our ED in January 2023 with internal medicine issues, the diagnostic accuracy was assessed by comparing the diagnoses made by ED resident physicians and those made by ChatGPT with GPT-3.5 or GPT-4 against the final hospital discharge diagnosis, using a point system for grading accuracy. RESULTS: The study enrolled 100 patients with a median age of 72 (IQR 58.5-82.0) years who were admitted to our internal medicine ED primarily for cardiovascular, endocrine, gastrointestinal, or infectious diseases. GPT-4 outperformed both GPT-3.5 (P<.001) and ED resident physicians (P=.01) in diagnostic accuracy for internal medicine emergencies. Furthermore, across various disease subgroups, GPT-4 consistently outperformed GPT-3.5 and resident physicians. It demonstrated significant superiority in cardiovascular (GPT-4 vs ED physicians: P=.03) and endocrine or gastrointestinal diseases (GPT-4 vs GPT-3.5: P=.01). However, in other categories, the differences were not statistically significant. CONCLUSIONS: In this study, which compared the diagnostic accuracy of GPT-3.5, GPT-4, and ED resident physicians against a discharge diagnosis gold standard, GPT-4 outperformed both the resident physicians and its predecessor, GPT-3.5. Despite the retrospective design of the study and its limited sample size, the results underscore the potential of AI as a supportive diagnostic tool in ED settings.